ROUNDTABLE ROADMAPTO MENTAL DISABILITY MANAGEMENT IN 2004-05

The Business Years for Mental Health

The management of mental disabilities in theCanadian workplace is a matter of urgent necessity.

Often the return-to-work from mental illness is a punishingexperience for employers and employees alike.

In an economy which puts an everyday premiumon the cerebral skills and mental performance

of men and women in their prime earning years, amaster plan for mental disability management is a concept

whose time has come.

This is one step in that direction.

Comments are invited.

bill.wilkerson@gwl.caJune 25, 2004

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Roadmap Contributors and Advisers

“Our gratitude to these outstanding people. Their insights and knowledge wereextremely valuable.” Bill Wilkerson

Jocelyne Achat, TD Bank Financial GroupChristopher Anderson, Guscott and Anderson Disability ManagementMichael ArmstrongChristine Ball, Regional Municipality of DurhamMary Ann Baynton, Mental Health Works, CMHA (Ontario Division)Glenn Carmen, MedisysLloyd Craig, Coastcapital Savings; BC Roundtable on Mental HealthHeather Craig, BC Roundtable on Mental HealthClaudine Ducharme, Watson Wyatt CanadaPatricia Fryer, Centre for Addiction and Mental HealthMerv Gilbert, PhD, Gilbert Acton LePageWilliam Gnam, MD, Centre for Addiction and Mental HealthDavid Goldbloom, MD, Centre for Addiction and Mental HealthRichard Guscott, MD, Guscott and Anderson Disability ManagementDouglas Hanson, University of British ColumbiaWilliam J. Johnson, McGown & Johnson (Calgary)Samira Kaderali, Towers PerrinSidney Kennedy, MD, University Health NetworkMichael Koscec, Entec CorporationDaniel Lalonde, Unum ProvidentRichard Levin, Levin Zeldin Litigation Counsel, (Toronto)Richard Lu, MD, Toronto Hydro CorporationTeresa Maleszewski, Canada Post CorporationRoger McIntyre, MD, University Health NetworkSue Morris, ScotiabankBrian Mullen, Dofasco Inc.Larry Myette, MD, Healthcare Benefit TrustPatricia Rockman, MD, University Health NetworkMichael Ross, MD, Careful Disability ConsultantsSandra Routledge, Watson Wyatt Canada*Bruce Rowat, MDRena Scheffer, Centre for Addiction and Mental HealthRichard Siegel, WarrenShepellJose Silveira, MD, University Health NetworkDoug Smeall, ATF CanadaSarah VanderBurgh, MD, Unum ProvidentWolfgang Zimmerman, NIDMAR

* Our special thanks to Dr. Rowat for his on-going input to the Roundtable. Dr. Rowat is Staff Physician,Department of Medicine, University Health Network; Associate Professor, Department of Medicine,Faculty of Medicine, University of Toronto; Chief Medical Advisor, BMO Financial Group; and MedicalDirector for Canada, Sun Life Financial

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ROUNDTABLE ROADMAPTO MENTAL DISABILITY MANAGEMENT IN 2004-05

The Business Years for Mental Health

NEWS SUMMARY

Roundtable Roadmap Targets the “Punishing Experience” Employees Face in Returning to Work from Mental Illness

Business Warned That Its Best Employees May be Most Vulnerable

TORONTO, Ontario (June 25, 2004) – Returning to work from the disabling effects ofdepression, anxiety disorders and substance abuse can be a “punishing experience” and aRoadmap was unveiled today to help smooth the way for employers and employees alike.

The Roadmap was developed and released by the Global Business and EconomicRoundtable on Addiction and Mental Health after weeks of consultations with medical,disability and human resources experts along with actual employees who lived throughthe experience.

Roundtable Senior Chairman Michael Wilson, former Finance Minister, set the stage forthe Roadmap by reminding business leaders that disability not life expectancy is theprincipal public health issue of the 21st century.

And disability, by definition, is a business issue. Beyond that, unipolar serious depressionand ischemic heart disease are pegged to become the leading sources of workdays lost inthe global economy.

The Roadmap – described as emergency measures encourages companies to adopt the“Wilson Principle” by expanding their success in physical health and safety to mentalhealth and safety. This has been argued persuasively by Michael Wilson.

Last February, the Roundtable released a slate of mental health and safety guidelines forboards of directors. In the fall, it will release leadership guidelines for CEOs.

Meanwhile, the Roadmap aims at the pressing concerns of returning to work from mentalillness and urges companies to incorporate mental health in their corporate health andsafety policies.

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The Roadmap says companies should help educate their employees about the higher-than-average risks of depression faced by those living with so-called physical chronicconditions such as diabetes and heart disease.

In fact, depression has been found to multiply the risk of sudden death amongconvalescing heart attack victims. It may also contribute to the onset of stroke.

The Roadmap characterizes depression itself as a “physical disorder with psychologicalimplications like other chronic illnesses.”

Vulnerable Segments

The Roadmap says a “clear demographic” is emerging as to which segments of the laborforce are more vulnerable to mental illness – namely, men and women in their primeworking years, employees in the 10th - 14th year of service with the same employer andnew entrants to the work force.

This information will inform workplace education initiatives and the Roadmap says a“foundation in fact” is essential to all forms of disability management but especiallymental disability.

The Roadmap also addresses the legal obligations of employers and unions in the courseof an employee’s return to work.

These obligations include the duty to accommodate an employee’s gradual return to full-time status – which means making temporary not permanent work arrangements duringthe employee’s absence.

In work sites where employees are members of a bargaining unit, the duty toaccommodate is shared equally by the employer and the union.

Overrides CBA

Under some circumstances, this duty to accommodate can even override a collectivebargaining agreement (CBA) including seniority provisions or bumping clauses.

Roundtable Co-Founder and CEO Bill Wilkerson says this point was researchedspecifically because of the confusion he found in certain cases which came to hisattention.

Mental illness is explicitly referenced in Canadian human rights law and theSaskatchewan Labor Relations Board cited a union for its failure to adequately representan employee suffering mental illness. The employee had been fired.

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The Roadmap suggests that to protect themselves, their employees and their members,employers and unions should retain the services of human rights experts and place thisexpertise at the employee’s disposal during the mental disability return-to-work process.

The Roadmap also advances the concept of a staff ombudsman for mental health basedon a model in place at Scotiabank.

The Roadmap is a first step toward a master plan for mental disability management to beanchored, in the future, by international standards to guide the evolution of best practicesfor the prevention and management of mental disability. This does not now exist. TheRoundtable will consult the World Health Organization on this matter.

The Roadmap:

• Says that problem job stress and home stress are synergistic.

• Emphasizes the need to give treating physicians detailed information on thedisabled employee’s duties and pressures as part of the treatment, recovery andRTW plan.

• Unequivocally reminds employers that the goal is to return employees to workfull-time – gradually. With mental disability, this objective may be disavowed.

• Alerts employers and employees to the predictors of depressive symptoms amongdifferent occupations.

• Warns employers serious depression, on average, takes an employee off the jobfor 40 days and early detection and treatment are key to reduce that.

• Says that the longer an employee is off work for any reason, the less likely itbecomes that they will ever return. 75 per cent come back after 12 weeks; two percent after one year.

• Says contact and communication between the workplace and the employeethrough the disability and RTW periods is key. Isolation deepens depression.

• Warns employers and employees that the threshold of highest risk in themanagement of mental disability is the point at which the employee is cleared byhis/her physician to return to work.

• Recommends employers should allow employees to bring a member of theirfamily, trusted co-worker, friend or their physician to the re-entry interview.Otherwise, employees are required to attend alone at this very sensitive moment.

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• Advises the employer to defer discussion of the “relationship issues” hung-overfrom the pre-disability period. This comes later. First welcome the employee backand reassure the individual his or her job is waiting.

• Recommends that the direct supervisor or manager of the employee be given theincentives and accountability for the employee’s timely and gradual return-to-work full-time.

• Introduces “The Green Chart” – an innovation to collect and house informationneeded by the physician, case manager, employer and employee to build a RTWplan.

• Supports a case manager or “quarterback” approach to mental disabilitymanagement. Process management of this nature is familiar ground as a businesspractice.

• States the importance of performance management techniques to “smoke out”mental health problems before they deteriorate.

• Offers business a “rule-out-rule” to separate mental health symptoms from gardenvariety performance and relationship problems.

• Makes specific suggestions for supervisors and employees to work together inmaking the gradual return-to-work process really work.

• Illustrates how employees can help themselves through the personal action plan ofone young mother recovering from bipolar disorder.

• Says employers must understand that the employee’s recovery and gradualreturn-to-work must be mutually-reinforcing. These are not absolutely separateand distinct phases.

• Reminds employers that job accommodations needed for these purposes areinexpensive and not disruptive but require a supportive boss. Which is whymanagers and supervisors should be actively engaged in the RTW process andheld accountable for the outcome.

• Paints a detailed picture of the faces of problem stress and burn-out among middlemanagers and advises employers to rein-in 10 management practices most likelyto precipitate or aggravate mental health problems.

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Refer: bill.wilkerson@gwl.ca 416-343-5337

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ROUNDTABLE ROADMAPTO MENTAL DISABILILTY MANAGEMENT IN 2004-2005

The Business Years for Mental Health

By Bill WilkersonCo-Founder and CEO of the Roundtable

(This Roadmap contains practical suggestions for facilitating an effective mentaldisability management program from governance and policy to practices, protocols andplanning.)

Urgent Necessity

In 1996, the Harvard School of Public Health found that disability, not life expectancy,was the top health issue of our times – and that depression is the leading source ofdisability which makes it a business issue.

In fact, depression and heart disease are emerging as the leading sources of work yearslost in the global economy. Beyond their economic impact, these conditions aremedically and physically linked.

To rein in these trends, business can build on substantial progress that has been made inthe past 20 years in physical health and safety at the workplace.

Honorable Michael Wilson, The Roundtable’s Senior Chairman, urges companies toextend this ethic and experience to mental health and safety.

The purpose: to unify physical and mental health within a single environmental, healthand safety (EHS) system.

The Roundtable is committed to doing what it can to promote the Wilson Principle as anintegral part of modern business practices and workplace health standards. This Roadmapis a first step toward:

� International standards governing the return-to-work (RTW) from mental illness.

� Fusing physical and mental disability management into a distinctive construct thateliminates the stigma and segregation of mental health problems standing apartfrom the mainstream of employee health and safety.

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Unmanaged Costs of Short-Term Employee Absence

Many Canadian companies neglect the costs or causes of short-term absences amongemployees. As a result, all too often, they neither identify nor deal with the underlyingreasons for the employee’s absence from work such as illness or stress-induceddowntime.

Which means this:

� A significant portion of the costs of business – represented by employeedowntime and absence – are absorbed randomly, neither funded nor managed.

� In fact, long and short-term disability now cost business twice as much as workerscompensation.

These are principal findings of Watson Wyatt Canada’s seminal “Staying@Work” surveyand while employers signalled to Watson Wyatt their growing concern about stress-related and mental health problems –

� Less than a third describe their return-to-work and case management programs aseffective.

� Only one-in-five communicate with their employees about disabilitymanagement.

� Most resist “innovative approaches” and settle for mediocre return-to-workresults.

In this light, employers are well-advised to re-examine their approach to the managementof mental disabilities.

RTW: Process or Punishment

The return-to-work from weeks or months of disability leave due to mental illness –probably depression and anxiety, sometimes together – can be a punishing experience.Among many companies, the “process” is unorganized and punitive.

Many, maybe most, managers are inexperienced and untrained in handling mental healthissues at work. No one taught them. Society hasn’t taught itself. No one’s the villain inthis drama. Solving the problem is a joint venture.

These emergency measures – this Roadmap – draw on the expertise of human resourcesand health professionals, disability managers and – notably – individual employees who,themselves, have navigated these difficult waters.

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Later, the Roadmap traces the action plan of one young mother as she returns to workfrom bipolar disorder. It is savvy and instructive.

At the heart of this matter – for employers and employees both – is the obvious butelusive goal of returning employees who have been disabled by mental illness – probablydepression – to work full-time.

This goal binds employer and employee. It expresses the employment contract. Often,though, in the return to work process involving mental ill health, it goes unstated, notbelieved. This is unwarranted.

Study after study shows that employees returning to work from mental illness do sosuccessfully when they receive proper treatment. Depression is beatable and treatable.But too few people who need treatment seek or get it. And seven out of 10 are men andwomen in the labor force.

THE ROUNDTABLE ROADMAP

This is a Roadmap of many steps. The sequence – as laid out here – is not pure. Somesteps are plain. Some complicated. Some easier spoken than taken.

The goal of this paper is to begin. The Roadmap will be refined, altered and re-drawn inthe months to come. We welcome feedback. We need it.

I The Wilson Principle

This is the principle articulated by Mr. Wilson to incorporate mental health into broaderenvironmental, health and safety policy and – in turn – linking this enhanced EHS toperformance management standards observed by the company overall. We recommendthat employers adapt and apply this principle accordingly. Alcan Inc. is a good model.

II Governance

In February, 2004, the Roundtable published a Board of Directors’ Guideline on MentalHealth and Safety. This was endorsed by top board chairs and CEOs of leading Canadiancompanies. Text of this Guideline is available elsewhere on this website.

The effect of this board guideline is to place mental health and safety on the governanceagenda of public and private companies, report this action to shareholders and support orencourage CEO leadership in this area. The Roundtable is working with publiccompanies who wish to customize and adapt it. Consult this Guideline.

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III CEO Goals

The Roundtable’s principal theme this year and next is corporate leadership in mentalhealth. Chief and senior executives who participate in the Roundtable have pronounced“leadership” as the key element in preventing mental disability and promoting mentalhealth in the labour force.

In this light, the Roadmap guides employers to four strategic business goals recentlyarticulated by participants in the Roundtable’s first-ever CEO Survey on Mental Health.

These goals are:

1. Maintaining a productive workforce2. Recruiting and retaining the most talented personnel3. Maintaining high standards of customer service4. Remaining competitive and profitable in the long-term

Business executives are speaking out on this subject. Please consult “In Their OwnWords” which appears as an attachment to this Roadmap.

IV Policy Aims

Like any road, this one will be more navigable with curbs and directional signs. To thatend, we recommend a slate of five policy objectives which support the CEO’s goalsnoted above. These fit nicely within a unified EHS strategy.

1. Portfolio approach: Incorporate existing investments in employee health into asingle, integrated portfolio of expenditures and outcomes. For example, the costs ofgroup health – and particularly prescription drugs – may help to hold disabilitypremiums down. Employers need to evaluate this return on this investment.

2. Education and training: Give employees every opportunity to learn about mentalhealth and train executives and front-line managers to recognize and respond properlyto co-workers (and direct reports) in distress. Tap into the expertise of those veteransof mental healthcare -- “consumers/survivors” -- who have valuable lessons to share.

3. Primary prevention: Identify workplace practices which pose material risks to thehealth of both the employees and the organization and make needed changes throughpositive, not punitive, incentives. Consult the Roundtable’s top ten list later in theRoadmap.

4. Secondary prevention: Put into place early detection, referral, and access-to-treatmentprotocols as a means of promoting early intervention. This is easier said than doneand a Roundtable Roadmap to Prevention will be developed as part of this series.

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5. Gradual Return-to-work: Apply this concept universally to all forms of employeedisability including those involving mental health problems. In doing so:

� Employers do not need to know the nature of the diagnosis of the disablingillness that is involved in any given case. This information is private andconfidential.

� Employers do need to understand, support, and participate in a return-to-workplan which will inevitably involve customized adjustments in the content ofthe employee’s job or hours of work in order to make the transition gosmoothly.

� Employers need to know that while the employee is coming back, he/she isnot 100 per cent and gradual RTW is necessary to help the individual catch-upwith things, get up to speed and build tolerance and endurance.

V Get the Facts

Facts are the foundation of effective disability management, especially so in the case ofmental disability where a sticky residue of mythology and misinformation remains.

Get these facts about mental illness to your employees, executives, managers andsupervisors and give them every opportunity – and the incentives – to use thisinformation to the benefit of their families and themselves.

The numbers:

� In one day, 10 to 15 per cent of Canadians experience a mental disorder.� In one year, the number is 20 to 25 per cent.� In one generation, 37 to 40 per cent.� Fewer than 20 per cent of those who need treatment actually get it.� And 70 per cent of these people are in the labor force.

The physical properties:

� Depression and anxiety – by far the most common mental disorders – are notfunctions of character or weakness. These are physical conditions centred in thebrain but affecting the whole body.

� A U.S. court has ruled, for example, that bipolar disorder can be categorized a“physical condition” (Perez).

� Depression is linked to other common chronic physical disorders such as diabetes,hypertension, asthma, heart disease, or stroke.

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� A clear demographic is emerging. Men and women in their prime working yearsand valued employees with 10 to 15 years of service are uniquely vulnerable.

� These demographics and the links of depression to chronic illnesses helpemployers and employees define priorities or ‘target audiences’ for educationinformation about the risks of mental illness and the rewards of doing somethingabout it early.

Chronic connections:

� Those living with diabetes, epilepsy, thyroid problems, cardiovascular disease,digestive issues, liver disease, asthma are believed to be more vulnerable todepression.

� Like these other physical conditions, depression and anxiety have majorpsychological implications and can affect perspective, concentration and sleep;handling time pressures, feedback, multiple-tasks and change.

The functional effects of depression:

� Slumping performance at work.� Poor timekeeping.� Increased consumption of alcohol, tobacco or caffeine.� Frequent headaches or backaches.� Withdrawal from social contact.� Poor judgment / indecisiveness.� Constant tiredness or low energy.� Unusual displays of emotion, e.g., frequent irritability or tearfulness.

The signs of group stress:

� Disputes and disaffection.� Increased staff turnover.� Increased grievances and complaints.

The breeding ground of burn-out – a potential pathway to depression:

� A bad match between the demands of an on-going job and the individual’sresources and skills to handle those demands.

� Taking serious responsibility without authority, recognition or appreciation.

� Losing or lacking control over the things that need to get done.

� Work and role overload.

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� Unclear functional goals as a steady diet.

� Constant fire-fighting which seems useless or unnecessary.

� Losing private time all the time.

Ten distinct faces of problem job stress among middle managers:

1. Growing irritability and impatience, “no end in sight” reactions to even routinerequests for information.

2. Inability to stay focused, finishing other people’s sentences to “save time,”wincing at new ideas (who needs another new idea), being unable to sit still,looking distracted and far away.

3. Staying out of sight, keeping the world at bay, being testy about casualinterruptions such as a phone ringing, not looking up when talking to others.

4. Treating the concerns of others about workload and deadlines with contempt and“join the club” sarcasm.

5. Displaying frustration with one’s own boss in the presence of others and leavingangry voicemails after regular business hours.

6. Stretching the workday at both ends, calling in sick a lot, persistently late formeetings.

7. “Working at home” to avoid the negative energy of the office;

8. Limiting eye contact with others except to “react,” finding it painful to smileopenly, your cheeks heavy, a fuzzy feeling behind your eyes.

9. Finding small talk hateful. Tuning-out what others say. Missing deadlines, losingfaith in yourself and others, resenting and even alienating customers.

10. Eventually, physical symptoms of pain and burning, breathing troubles, backproblems. Burn-out may migrate to a diagnosable and dangerous medicalcondition.

Depression is linked to heart disease:

� About 20 per cent of people who suffer heart attacks exhibit signs of clinicaldepression at the time. In fact, depression can dispose individuals with damagedhearts to arrhythmia, a cause of heart attack.

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� The Montreal Heart Institute found that depression quadruples the risk of cardiacdeath among patients admitted to their care for unstable angina and the U.S.National Center for Health Statistics reports “there is evidence to suggest thatdepression may cause stroke or other cardiovascular events.”

� Cardiac patients suffering depression experience what experts call “decreasedheart rate variability.” Which means the heart of a depressed person never sleeps.

� Depression may increase blood clotting. In turn, this can impair the supply ofblood and oxygen to the heart. A cause of heart attack.

� The U.S. National Center for Health Statistics reports that “there is evidence tosuggest that depression may cause stroke or other cardiovascular events.”

VI Reduce Problem Stress at Source

Problem job stress can double, even triple the risks of worker disability associated withdepression, anxiety, substance abuse, back pain, on-the-job injuries and infections.

The Roundtable estimates that:

� Mental health problems are the primary and secondary issue in 60-65 per cent ofdisability insurance claims in Canada.

Statistics Canada reports that:

� Healthcare costs are nearly 50 per cent greater for employees who report highstress and the Canadian Policy Research Networks estimates that stress-relatedabsences cost employers nearly $4.0 billion a year.

The Canadian Centre for Occupational Health and Safety defines workplace stress as:

� The harmful physical and emotional responses to the demands of the job byemployees who lack the resources and control they require to meet thosedemands.

In these terms, it becomes clear that mental disability management involves more thantreating a medical illness. It is – to a significant degree – a bread’n’butter managementchallenge.

In this light, the Roundtable has identified 10 management practices – or, in some cases,behaviours – which appear most likely to precipitate or aggravate mental health problemsin the workforce.

1. Imposing unreasonable demands on subordinates and withholding informationmaterially important to them in carrying out their jobs.

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2. Refusing to give employees reasonable discretion over the day-to-day means andmethods of their work.

3. Failing to credit or acknowledge their contributions and achievements.

4. Creating a treadmill at work – too much to do all at once all the time.

5. Creating perpetuated doubt, employees never sure what’s happening around them.

6. Allowing mistrust to take root. Vicious office politics disrupt positive behavior.

7. Tolerating, even fostering unclear company direction and policies, job ambiguityand unclear expectations.

8. Sub-par performance management practices – specifically employee performancereviews – even good ones – which fail to establish the employee’s role in thecompany’s near or mid-term future.

9. Lack of two-way communication up and down the organization.

10. Managers rejecting, out of hand, an employee’s concerns about workload.

This leads us to this conclusion:

� Remedies are called for to eliminate and reduce the effects of these practices inthe 21st century work force as a matter of good business and good health.

VII Return-to-Work (RTW) From Mental Illness

Once an employee is off work, a pro-active return to work process is essential and twoimmediate objectives stand-out:

1. Keep the lines of communication open between the employee and the work place.Isolation predicts and deepens depression. It prolongs disability.

2. Returning this employee to work full-time. This is the employee’s wish and legalright. The employer’s natural advantage and legal obligation.

Two precautions:

� Like other chronic illnesses, coming back to work too soon, too fast, can impedethe recovery from depressive disorders;

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� At the same time, the longer an employee is away from work – for any reason –the greater the risk of them never coming back. For example, after 12 weeks, 75per cent return; after one year, 10 per cent; after two years, two per cent.

The purpose of mental disability management:

� Make recovery and a gradual return to work mutually reinforcing.

In turn:

� Employers can bridge these vital determinants by tracking, carefully – incooperation with the employee and his or her physician – the pace and timing ofthe employee regaining his or her capacity to perform the functions of the job.

� This is called return-to-function or functionality and, for the physician, one meansof measuring the reduction of symptoms.

The disability management challenge:

� On average, an episode of serious depression can take an employee off the job foran estimated 40 days. Which is longer than cardiac disease.

� Effective treatments of depression – better accessed – can change this picture andresearchers at the Centre for Addiction and Mental Health find that seventy-fiveper cent of those who get the treatment they need do, in fact, successfully returnto work.

But:

• About 80 per cent of the estimated number of Canadians who experience mentalill health each year do not get the treatment they need when they need it.

• As a result, high percentages of employees migrate from long to short-termdisability, even lose their job – especially – sadly – young people.

Job-to-Job:

� The predictors of depressive symptoms may vary among occupations;

� Among factory workers, the predictors of depressive symptoms include minimalcontrol over workload and excessive environmental noise.

� Among white collar employees, the predictors are role ambiguity, lack of controlover their work and a lack of support from co-workers.

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� Among teachers and the “caring professions” (including physicians andhealthcare workers) job strain is a predictor of depressive symptoms.

� Job stress and home stress have a synergistic effect. As a result, the line betweenis blurred between health conditions that are or are not work-related.

VIII The Green Chart

The RTW from mental illness may involve well-established procedures used in otherforms of disability – among them low back pain. But common to each is this tested edict:plan ahead.

A return-to-work process begins when the employee’s disability claim is approved andthe leave period begins. At that time:

� Open what we might call a Green Chart headlined by the stated goal of thatemployee returning-to-work fulltime – gradually – and anchored by theunification principles governing recovery, return-to-function and return-to-work.

The Green Chart will house key information that the employee’s physician needs in orderto develop a clear picture of the implications of the disorder on the individual’s capacityto work. The physician needs to know:

� Specifically what functions the employee performs, patterns of absence ordowntime, say, over the past 30 days, and the pace, dynamics and history of thework environment in which the employee routinely functions.

� The amount of interpersonal exchange, planning skills, attention to critical detailand the pace of work which characterizes the employee’s duties.

This helps the physician make a judgment – in the face of the employee’s illness – as towhat considerations or accommodations might be necessary to assist in bringing thatemployee back to work.

In California, for example, psychiatrists are expected to address the employee’s ability inareas such as:

� Understanding and following instructions.� Performing simple and repetitive tasks.� Maintaining a work pace appropriate to the word loan.� Relating to other people beyond giving and receiving instructions.� Influencing others, accepting instructions, planning.

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The Green Chart will also house information the employer needs to support theemployee’s recovery and return-to-work including –

� Guided work-to-home and home-to-work communication between the employeeand his or her supervisor and co-workers. This is absolutely vital.

� And, information the employee needs to know in order to understand the RTWplan, to participate in building and believing in it.

IX Quarterback System

The concept of case management is a quarterbacked system already well-established inbusiness in the form of workplace teams and process management. This concept is thekey to a successful RTW process.

The quarterback is called a case manager. It is well-established that physicians prefer notto be the sole gate-keeper in the RTW process. Additional expertise is called for –ranging from the management of job and workplace pressures to occupational health.

One of the first steps the case manager takes is this: meeting with the employee and thencontacting the employee’s physician and discussing the nature of the medical imperativesgoverning the individual’s recovery. This does not suggest the case manager garnersaccess to the employee’s medical file. Not at all.

The quarterback – or case manager – keeps the unification principles in sight throughoutin order to ensure the recovery process is fully-protected – flowing gradually into anassessment of the employee’s return to function and, gradually, return to work – full time.

The quarterback – or case manager – helps the physician, employer and employeeidentify those job issues that will influence the pace and timing of the “return” elements.

The Green Chart becomes the case manager’s blueprint. A water color effect.

As such – green or blue – this device houses a written RTW plan. The Green Chart doesnot contain confidential medical information.

Let us emphasize this:

� The RTW plan deals with returning-to-work full-time gradually without referenceto diagnosis but with clear reference to modifications of job content or hours ofwork that may be required to accommodate this.

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And this:

� The employer’s duty to accommodate is clear. Managers and co-workers are theface of the employer in this matter. They implement this duty and represent theemployer in doing so.

� As a result, managers and co-workers must perform a constructive role in theRTW process and not doing so – whatever the employer’s declared intent orpolicy – could expose the employer to a human rights violation.

X Making Reasonable Accommodations

Case managers and physicians are the key advisers to determine what workplaceaccommodations are needed by employers to facilitate the employee’s gradual RTW.

These two specialists, therefore, need to develop a clear picture of the demands of the jobin order to translate this information into “functional” terms – including, for example,difficulties the returning employee may yet have in –

� Concentrating for any length of time.� Dealing with noise and distractions.� Managing emotions and time.� Maintaining stamina during the workday.

These concerns can be resolved by –

� Flexible and part-time scheduling.� Longer or more frequent work breaks.� Self-paced workloads.� Minor changes to the work setting such as –

1. Like moving the employee closer to natural light.

2. Reducing noise levels – a common EHS practice to preserve employeehearing.

3. Make it easy to get water, tea, soft drinks or crush ice to counter the effects ofsome medications. Dehydration can produce fatigue.

Supervisors and RTW employees can work together to ensure that these kinds ofaccommodations are workable and easy. Some tips from the experience of others:

� Make daily ‘to-do’ lists and check items off as they are completed.

� Remind each other of important deadlines. Give and get extra feedback.

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� Divide large assignments into smaller tasks and goals.

� Look for opportunities to provide positive reinforcement.

� Use written job instructions to the extent that this is helpful.

� Ask the employee which is the best time of day for them. For some, it is themorning, for others, the afternoon.

� Possibly avoid working Mondays which are “crazy days” in most places of work.

� Agree to open communication – devise discrete one-on-one hand signals, ifnecessary, to indicate unwelcome stress is building up and it is time for a time-out

� Make sure the employee is treated as a member of the team and not excludedfrom social events, business meetings or other activities relevant to the job.

� Do not be excessively protective.

One Person’s Action PlanThe Return-to-Work from Bipolar Disorder

Steps reported to the Roundtable by one young mother and wife as she prepares toreturn-to-work full-time.

1. Take my medication as directed.

2. Get at least 7 hours of sleep.

3. Exercise at least 30 minutes per day at least five times per week.

4. Eat sensibly, avoid overeating and use food supplements.

5. Take time to read daily (this is time for relaxation).

6. Do not overextend or over-schedule self.

7. Keep meals and clean-up during the week simple. Spend time with family.

8. Understand that a job task doesn’t have to be done perfectly to be doneproperly.

9. Keep involved in mental health advocacy and volunteering.

10. Say “no” to extra work or obligations if I feel overwhelmed.

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11. Schedule major activities flexibly to incorporate unexpected events.

12. Stop pressuring myself to get work done right away. Learn when to take abreak.

13. I need an outlet for goal oriented activity when I feel manic. Last time Iexperienced hypomania, I was extremely productive and read three books infive days.

14. I will do majority of housework on Saturday. I will delegate some to mydaughters.

15. I must work at maintaining focus on what I am doing. It’s OK to multi-task –but I must make sure that I do not stray too far away from the main task athand.

Let us emphasize this:

� Reasonable accommodations for the return-to-work from mental illness are notcostly and can happen informally, within the nature of the job, without fanfareand no disruption of others.

� As the Action Plan shows, an employee can make her own accommodations inother facets of her life which enhance the return to work experience for bothemployer and employee.

XI Re-Entry Interview

Ironically, the most telling and risky milestone in the RTW process may be the point atwhich the employee is cleared by his/her physician to return-to-work.

The employee is likely still in recovery mode and – like anyone coming back from anyillness – uncertain, even brittle. This is natural. There are certain protocols, planning, andsensitivities, therefore, the employer must observe:

� The employer must welcome the employee back, first and foremost, and affirm itsduty and desire to accommodate a smooth re-entry.

� Make it clear that the employee’s job is waiting for her or him. The assumptionbehind this: the employer has not filled the job permanently.

� Do not make the “residue of issues” which developed in the immediate pre-leaveperiod the order of first business. These matters can and should be addressed laterin the process.

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� Over and above the case manager or union rep., the employee should have theoption of being accompanied at the re-entry interview by a family member,personal friend, trusted co-worker, or his/her physician.

� It is critical that as the gradual return-to-work proceeds, the employee is notisolated for weeks after the re-entry interview. This can be destructive to his/herhealth. Being alone at this point is both unnecessary and unhelpful to the RTWprocess.

XII The Duty of Unions

Mental illness is explicitly protected against discrimination in human rights legislation.Courts have ruled that impairment due to disability is unique to the individual. Jobaccommodations must – and can – be the same.

Disability is defined as the gap between what a person can do and needs or wants to dowhile mental disability refers to the effects of any mental disorder regardless of cause.

The duty to accommodate an employee’s return-to-work from mental illness fallssquarely on the employer and – in a bargaining unit – the union – up to the point of unduehardship.

This is a matter of law.

1. Employees returning to work after an absence due to a mental disability such asdepression must be accommodated with modified work through changes in theirexisting job or through alternative positions.

2. The employer may assume the union’s voice in RTW matters is, by definition, thevoice of the employee. For RTW purposes, the employee should make thatchoice.

3. Unions, and employers, in fact, should recruit independent human rights expertsto advise all parties including the employee on whether his/her rights are beingobserved and protected.

In a five-point analysis by lawyer William J. Johnson of McGown, Johnson in Calgary,we learn that:

1. Unions have a responsibility to accommodate and escape this duty through anyprovision of a collective bargaining agreement.

2. Unions and co-workers of the RTW employee must participate in the search foran accommodation – and cannot flatly refuse on the basis of seniority or jobposting rights.

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3. Neither can the employer ask the union and co-workers to waive seniority rightsunless “no other reasonable alternative resolution exists.”

4. Unions have a duty to represent their members “at the higher end of the scale” inmatters concerning a disabled employee. This is particularly true when anemployee is mentally disabled and the issue is termination.

5. In one case –

• The union was “held to have violated its duty of fair representation to theemployee” by failing to seek arbitration in the case of an employee disabledby depression who was fired for not following orders and getting along withfellow employees.

• The Saskatchewan Labour Relations Board held that “the union failed to takesufficient account of the mental disability experience by the employee and ittherefore discriminated against him in handling the grievance.”

XIII Mental Health Ombuds

Scotiabank has developed an innovative means of providing assistance and support toemployees with workplace mental health concerns through the services of its long-standing Ombuds program.

This is a confidential, informal, unbiased, neutral resource for employees seeking supportin managing workplace challenges and now plays a useful role in helping employeesprevent and manage mental health issues associated with their jobs.

This approach gives employees the opportunity to raise issues without fear of judgment,reprisal, or loss of privacy and serves as a resource for working through issues that areoften cited as primary sources of workplace stress.

CIBC has proved a reduction in sick leave as a result of enlightened mental disabilitymanagement strategies. TD Bank Financial Group is tackling the issue head-on.

XIV Accountability and Incentives

Employers are bound to make temporary not permanent work arrangements during theemployee’s absence.That being so:

• It is advisable to plan the accommodation process well in advance of the point atwhich the employee is cleared by his/her physician to return-to-work gradually.

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� The RTW work plan must include the act of giving co-workers – immediatelyaligned with the disabled employee – enough information – cleared by thatemployee in advance to understand how their action will affect the process ofaccommodation under law.

Further:

� Accountability for the success of the RTW process should be vested – insignificant measure – in the line and staff managers responsible for thatindividual’s performance on-the job – guided by the case manager.

� The line manager and human resources personnel should receive financialincentives to bring about a successful RTW wherein the employee comes backfull-time gradually and remains successfully on the job for six months andcounting.

� Unilateral terminations (without cause) or downsizing of RTW employees withinsix months of their return can be viewed suspiciously.

XV Symptoms and Job Performance

The crossover between unrecognized symptoms of a mental disease and emergingperformance and relationship problems on-the-job is one of the most complicatedfeatures of mental disability management.

Symptoms of mental conditions can be mistaken for a “negative attitude” on the job. Thisnever happens, of course, when an employee has a physical injury such as a broken arm.

In that case, it becomes self-evident he or she cannot function 100 per cent. But withdepression and anxiety, nothing is self-evident to managers or co-workers.

Nonetheless, like other injuries and illnesses, depression affects the performance of theindividual employee – but the reasons usually go undetected and unrecognized.

Researchers have found that employees with depression tend to ‘play through theirinjury’ (to use a sports phrase) and trudge to work each day not recognizing they have amedical condition. Downtime ensues. Part of the workday gets lost.

These random absences represent a bigger cost to business than disability leaves. This isone complication in managing mental disability. There is another.

Many managers today do not deal with performance issues effectively, defer HRproblems, avoid them or wait for a downsizing solution. Also, formal job descriptionsfrequently do not describe the actual responsibilities of the employee.

On the other hand, performance management is an important tool in the earlyidentification of job stress, distress and developing medical conditions. For example:

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� The observance of sound performance management practices combined withempathetic two-way communication between the “direct report” (employee) andhis or her boss, will ultimately smoke out symptoms of depression and anxiety.

� But when performance concerns do not get discussed or dealt with in a timelyway, important conversations do not happen.

� Further, the build-up of performance problems often parallels the decline ofworking relationships, thus creating a residue which becomes a trap waiting tosnare the employee when he or she returns to work from sick leave.

XVI Rule-Out-Rule

A person suffering depression – often a top performer, loyal employee and good friendamong job peers and supervisors alike – may exhibit behaviors that mimic bad ornegative attitudes. It may be a symptom not an attitude.

The failure to draw a distinction between illness and attitude (for want of a better phrase)can cost an employee their job and the company an otherwise valuable asset.

But how can one tell the difference when work relationships are strained by thatindividual’s failure to meet their obligations at work, proneness to anger, inability toconcentrate or communicate appropriately?

The Roundtable suggests the “Rule-Out-Rule”.

When an employee is performing badly, especially where this contradicts pastperformance, introduce the “Rule-Out-Rule” to rule out (or, rule in) health problems asthe source of performance deterioration.

This 3-step process generally involves:

1. Train supervisors, managers and executives to ask questions of an employeewhich both respect their privacy and help them to consider whether a healthconsultation is worth doing before the performance issues are reviewed in moreconventional terms.

2. Encourage the employer to consult his/her family physician or another healthprofessional including the company’s EAP provider if one is available.

3. Defer the “performance discussion” until this health review is complete and onceit is, the employee has information – confidential and private – with which tomake a decision about next steps in consultation with his/her boss or theemployer’s confidential staff.

The Roundtable will offer a training program in 2005 to help employers use the Rule-out-Rule.

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XVII The Insurance Contract

Line managers not just HR or compensation staff should have a working knowledge ofthe company’s disability arrangements. For example:

� Short-term disability (STD) is often paid by the employer and administered by aninsurance company. Other firms purchase STD insurance from an insurer and paypremiums. Employees may contribute.

� These distinctions are moot. The sick-leave or STD period is the critical phase oftreatment and recovery to avoid long-term disability (LTD), arrest symptoms, andbegin the recovery process. The employer must assume ‘ownership’ of the STDprocess for these purposes.

� Meanwhile, LTD insurance is usually purchased, employees may pay part or theentire premium and this is really a form of income protection. Too frequentlyemployers defer the question of the employee’s recovery and RTW entirely totheir insurer.

� While the insurer will offer valuable assistance and well-founded expertise indisability management, the employer must remain engaged and retain ownershipof its own investment in its own employee.

Postscript

The Young and the Brave

Depression and anxiety are not a function of character, weakness or old age. But they areconditions of the young, productive, caring, responsible, brave and strong.

� Canadians 15-24 are the most vulnerable to mental health problems particularlydepression. The average age of onset of anxiety disorders in Canada is age 12.

� Men and women in their prime working years and with 12 to 14 years of servicewith the same employer seem to be uniquely vulnerable.

� Nurses and school teachers experience depression at rates higher than the nationalaverage.

� Decorated war heroes and bold life-and-limb rescue pilots suffer traumatic stressinjury and depression.

� Major league baseball players – and other powerful athletes – use depressionscreening services made available to them by their ball clubs.

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Next Steps

Comments are invited. Better ideas are welcome. Debate encouraged. The Roadmap –much improved, no doubt – will re-appear later this summer.

Comments can be emailed to: bill.wilkerson@gwl.ca or mailed to:

Global Business and Economic Roundtable on Addiction and Mental HealthGuest Resident at Great-West Life Assurance Co.

200 King St. W., 14th FloorToronto, ON M5H 3T4

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Business Leaders Speak Out on Mental Health

“In Their Own Words”

These are the verbatim accounts of statements made by senior business people in a trilogy of Roundtable meetings hosted by the leaders of

TD Bank, Scotiabank and CIBC in theirBoardrooms in 2002 and 2003.

“The case for the importance and severity of mental disability is incontrovertible and anyboard of directors that doesn’t insist on having environment, safety and health on itsagenda – with a special emphasis on mental health – is not discharging its governanceresponsibility.” John Evans, Chairman of the Board, Torstar Ltd.

“Mental health and work place stress must be counted as one of the top business issuesfor all of us who claim that our people are our most important asset and the basis of oursuccess or failure.” John Hunkin, President and CEO, Canadian Imperial Bank ofCommerce

“It is important to put this issue into the context of both our corporate values and ourmanagement system. The health and welfare of our employees is inseparable from theoverall success of Alcan.” Brian Sturgell, Executive Vice-President, Office of thePresident, Alcan Inc.

“How we treat people in the workplace is at the heart of sustaining business performanceover the long-term. This is a big agenda and a critical one.” David Wilson, Vice-Chairman, Scotiabank and CEO, ScotiaMcLeod

“Today’s economy puts a premium on information and innovation. This is an economy ofmental performance where the capacity of employees to think, be creative and beinnovative is key to the competitiveness of all business – including my own.”Gordon Nixon, President and CEO, Royal Bank Financial Group

“Business must have a mental health agenda.” Paul Godfrey, President and CEO,Toronto Blue Jays

“We simply must get our arms around this issue for sound business reasons.” Tim Price, Chairman, Brascan Financial Corporation and the Roundtable’sCo-Founder and Chairman

“Business, definitely, has a strategic interest in the mental health of the labor force.”Nancy Hughes-Anthony, President and CEO, Canadian Chamber of Commerce

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“A case can readily be made – with lots of data to back it up – that investing in the mental healthof our workforce isn’t a leap of faith, it is a reasonable and prudent thing to do.”Jamie Anderson, Deputy Chairman, RBC Capital Markets and Chairman, Centre forAddiction and Mental Health

“When the Roundtable was formed, many of us were from Missouri. We had to be convincedthat mental health issues deserved to have a distinctive place on the corporate agenda. For one, Idon’t need more convincing.” Colum Bastable, President and CEO, Royal LePage Ltd.

“The pay-off of investing in the mental health of our people will be huge.” Don Tapscott, Co-founder, Digital 4Sight and President, New Paradigm

“We endorse the goal of preventing disability associated with depression, anxiety and substanceabuse. We believe in early intervention.” David Henry, Managing-Director, Toronto,Great-West Assurance Company

“The cornerstone of what we have done in our organization is to establish mental health as apriority – that is, to understand the problem and provide our staff with the necessary tools andsupport to address it.” Don Pether, President and CEO, Dofasco Inc.

“The whole discussion (of employee mental health) boils down to this: do we value humancapital. For some corporations, this is not just a matter of recognizing the value of human capital,it is a question of leadership.” Ed Kilroy, President, IBM Canada

“Leadership in this area must come from the top. HR departments must be empowered.”Lynton J. Wilson, Chairman of the Board, Nortel Networks Corp.

“The issues that we’re addressing in workplace mental health are questions of good managementand that’s key criteria for assessing financial performance or the future performance of anyinstitution.” Paul Haggis, President and CEO, Ontario Municipal Employees RetirementSavings (OMERS)

"Just as every physical injury carries with it identifiable, unwanted and, to my mind, fullypreventable business costs, and if compassion isn’t enough, we have a self-interest inrestoring productivity to its highest possible level if it is being constrained by a mentalillness.” Former Syncrude CEO, Eric Newell

Refer:

Bill Wilkerson416-343-5337